Primary Care
Physician perspectives on preventive care, chronic disease management, and evidence-based primary care practice.
Recent Discussions
How do you approach treatment-resistant depression and anxiety related to menopause refractory to SSRI/SNRIs and hormone replacement therapy?
First, I try bupropion and have found that the dopaminergic medication is excellent for refractory depression, especially as one ages because dopamine gradually decreases 10% per decade (Berry et al., PMID 27807030). If bupropion doesn't help, then I have used pramipexole quite effectively over the ...
Do you look for local IgE production in the nares with negative SPT and IgE testing if the clinical history suggests AR and the patient desires AIT?
I do not check for local IgE production or perform nasal allergen challenges for local allergic rhinitis. I just offer these patients the combination of a nasal steroid and nasal antihistamine.The 2020 Rhinitis Practice Parameter has a nice summary of local allergic rhinitis."While the literature su...
Are there any new treatments for erosive osteoarthritis of the hands?
Unfortunately, the short answer is “no.” Hand OA, in general, is one of the more refractory forms of OA, and erosive OA is even more so. A variety of theoretically useful approaches have been tried, based on our understanding of inflammatory arthritis in general. However, recent placebo-controlled t...
Given the risk of hypocalcemia in dialysis dependent patients treated with denosumab, what is the best method of treatment for osteoporosis for these patients, and should we be transitioning to a different agent?
Hypocalcemia can be prevented by providing adequate calcium, 1,200-1,500 mg in divided doses daily, and adequate calcitriol to absorb it. Good results also occur when the patient has tertiary hyperparathyroidism with hypercalcemia.
How do you manage persistent cytopenias after FCR chemotherapy for treatment of CLL?
For persistent cytopenias after FCR, the initial approach would be supportive care. If no recovery after 12 weeks, consideration should be for a bone marrow biopsy to evaluate for aplasia, an autoimmune process like PRCA, or early MDS. The therapy after the bone marrow would be based on the result. ...
What are some helpful tips to identify and optimize visualization of the common bile duct on abdominal POCUS?
Good question! The common bile duct (CBD) can be difficult to visualize in general, but optimizing the gallbladder exam will also help to optimize the CBD. I am cautious about ruling out choledocholithiasis with POCUS, though a retrospective 2014 study showed that POCUS can be helpful in ruling out ...
How do you counsel patients with AUD about non-alcoholic (NA) beverage consumption?
I am not aware of any data to help with answering this question, so I am here offering my expert opinion only. I think of non-alcoholic beverages similar to how I think about vaping nicotine. There are incontrovertible harms associated with both alcohol and inhaled tobacco. The harms of vaping nicot...
Would you use oral cefixime as an alternative treatment for early syphilis in cases of benzathine penicillin G shortages?
Based on in vitro activity against T. pallidum and the study you cite, cefixime 400 mg BID for 14 days likely is effective for treatment of early syphilis (Klementová et al., PMID 40795115). However, I see no advantage over the recommended option of doxycycline (100 mg BID for 14 days) when BPG isn'...
How do you counsel patients on the risks vs benefits of naltrexone for alcohol use disorder with persistently elevated liver enzymes?
Before answering this question, it is first important to point out that obtaining baseline liver function tests (LFTs) is not necessary before starting a patient on any formulation of naltrexone (oral or long-acting injectable XR). However, it is essential to consider if the patient has an underly...
How would you approach hormone replacement therapy for perimenopause in a patient with increased risk factors for VTE?
Like many medical choices, this decision involves weighing trade-offs—specifically, the risk of venous thromboembolism (VTE) versus the burden of severe menopausal symptoms. If we focus only on VTE risk (and set aside the trade-offs related to menopausal symptoms and the controversial issue of breas...